SURPLUS REQUEST FORM Request ID: Request Date: // Request Status: Submitted Department: COS - Dean Pick Up Location: A Comments: Items in Hallway as you walk towards QTY Lot N Description Apple Monitors Y Box of Power Cables N HP Printer N Contact: Phone: Email: Surplus Action: Serial# Project Terry Byron /- tbyron@ncsuedu Pick-Up Asset Tag# Asset ID Condition Good Good CNB Poor HP Printer/Scanner THU Poor N HP Printer CNDJC Poor N HP Printer MF CNBGCK Poor N HP Printer JPBCBMM Poor N HP Printer PHBQH Poor QTY Lot N Description HP Printer Serial# PHBQD Project Asset Tag# Asset ID Condition Poor N HP Printer CNB Poor N Projector in Bag EW Poor Certifications Hazardous Materials Notice Y Certified By TBYRON // : AM Person/Department disposing of equipment that (i) may have been used to process hazardous materials, or (ii) may contain hazardous material which cannot be removed, or (iii) which contains radioactive materials, must receive clearance as appropriate from the Environmental Health & Safety Dept, or the Radiation Protection Office before this equipment may be surplused Data Security Note Y Certified By TBYRON // : AM When including devices that may have internal storage (eg, copiers, printers, scanners, projectors, etc) on this form, please check with the manufacturer for verification if storage exists If equipped with internal storage, it is the responsibility of the department to erase all data on the internal storage or remove it before turning the device over to Surplus Devices with internal storage retain images made during the life of the equipment Risk Management Y Certified By TBYRON // : AM Person/Department disposing of (i) tractors, mowers, skid steers or (ii) cars, trucks, vans and trailers, must provide signed copy of the surplus request with signatures from your department and Surplus Property to remove the item (s) from Risk Management Insurance Created By: TBYRON // : AM Last Updated: TBYRON // : AM